<form id="edit-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('ApplyCode')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-applyCode" data-rule="required" class="form-control" name="row[applyCode]" type="text" value="{$row.applyCode|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('InsuranceCode')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-insuranceCode" data-rule="required" class="form-control" name="row[insuranceCode]" type="text" value="{$row.insuranceCode|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('InsuredType')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-insuredType" data-rule="required" class="form-control" name="row[insuredType]" type="number" value="{$row.insuredType|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('InsuranceName')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-insuranceName" data-rule="required" class="form-control" name="row[insuranceName]" type="text" value="{$row.insuranceName|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('InsuredPerson')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-insuredPerson" data-rule="required" class="form-control" name="row[insuredPerson]" type="text" value="{$row.insuredPerson|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('ElectronicPaperUrl')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-electronicPaperUrl" data-rule="required" class="form-control" name="row[electronicPaperUrl]" type="text" value="{$row.electronicPaperUrl|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Amount')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-amount" data-rule="required" class="form-control" name="row[amount]" type="number" value="{$row.amount|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('InsuranceFee')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-insuranceFee" data-rule="required" class="form-control" name="row[insuranceFee]" type="number" value="{$row.insuranceFee|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('StartTime')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-startTime" data-rule="required" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[startTime]" type="text" value="{:$row.startTime?datetime($row.startTime):''}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('EndTime')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-endTime" data-rule="required" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[endTime]" type="text" value="{:$row.endTime?datetime($row.endTime):''}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Result')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-result" data-rule="required" class="form-control" name="row[result]" type="number" value="{$row.result|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Message')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-message" data-rule="required" class="form-control" name="row[message]" type="text" value="{$row.message|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('Time')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-time" data-rule="required" class="form-control datetimepicker" data-date-format="YYYY-MM-DD HH:mm:ss" data-use-current="true" name="row[time]" type="text" value="{:$row.time?datetime($row.time):''}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('CustomerId')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-customerId" class="form-control" name="row[customerId]" type="number" value="{$row.customerId|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('CustomerName')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-customerName" data-rule="required" class="form-control" name="row[customerName]" type="text" value="{$row.customerName|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('ProjectName')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-projectName" data-rule="required" class="form-control" name="row[projectName]" type="text" value="{$row.projectName|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('ProjectNO')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-projectNO" data-rule="required" class="form-control" name="row[projectNO]" type="text" value="{$row.projectNO|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('ItemName')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-itemName" class="form-control" name="row[itemName]" type="text" value="{$row.itemName|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('ItemNo')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-itemNo" class="form-control" name="row[itemNo]" type="text" value="{$row.itemNo|htmlentities}">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-2">{:__('ProductType')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-productType" data-rule="required" class="form-control" name="row[productType]" type="number" value="{$row.productType|htmlentities}">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-2"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-primary btn-embossed disabled">{:__('OK')}</button>
        </div>
    </div>
</form>
